Making the Case for Dental Coverage for Adults in All State

Making the Case for Dental Coverage for

Adults in All State Medicaid Programs

Author: Marko Vujicic, Ph.D.; Chelsea Fosse, D.M.D., M.P.H.; Colin

Reusch, M.P.A.; Melissa Burroughs

Introduction

Oral health is essential for overall health and wellness. Oral health is linked with systemic

health conditions and diseases as well as employment opportunities, economic stability, and

social connectedness. One cannot be healthy without a healthy mouth. Yet millions of adults

in America – particularly low-income adults – cannot afford the oral health care they need to

stay healthy, eat, work, socialize, and live pain free. Part of this disparity is driven by gaps in

dental coverage in federal and state policy, particularly dental coverage for adults enrolled in

Medicaid.

As the nation recovers from the COVID-19 pandemic and economic downturn, oral health

coverage is a critical gap in our health care system. For adults who rely on Medicaid, being

able to afford oral health care could be the key to recovering their health or getting a new

job. Yet millions of adults are left without oral health coverage, exacerbating health

inequities. Notably, the people most likely to get sick and lose jobs during the pandemic are

This Research Brief was written

in a partnership between the

ADA Health Policy Institute

(HPI) and Families USA and

Community Catalyst.

The Health Policy Institute is a

thought leader and trusted

source for policy knowledge on

critical issues affecting the U.S.

dental care system. HPI strives

to generate, synthesize, and

disseminate innovative research

for policymakers, oral health

advocates, and dental care

providers.

Community Catalyst is a

consumer health advocacy

organization that seeks to

engage policymakers and other

stakeholders to increase access

and affordability of care through

policy reform.

Families USA is a leading non-

partisan research organization

that provides public health policy

analysis with specific focus on

health care value, health equity,

coverage, and consumer

experience.

Contact the Health Policy

Institute for more information on

products and services at

[email protected] or

call 312.440.2928.

Key Messages



Oral health is essential for overall health. Providing adult dental coverage through

Medicaid improves access to and utilization of dental care among low-income adults and

has the power to reduce racial disparities, advance health equity, and lower medical care

costs.



We estimate the cost of implementing extensive dental coverage for adults in all state

Medicaid programs that do not provide such coverage. We estimate increased spending

on dental care as well as medical care cost savings stemming from improved oral health.

 Federal and state policymakers have various levers to promote oral health equity across

the nation, including designating dental services as a mandatory benefit category for

adults, establishing a baseline of comprehensiveness for adult dental services in

Medicaid, and bolstering state budgets to ensure adequate funding for successful

implementation.

also the people who face the biggest barriers to oral

health. People of color, tribal communities, older

adults, and people with disabilities are among those

who would most benefit from improved oral health

coverage in Medicaid.

In this brief, we review data on barriers to dental care

for low-income adults and the current landscape of

dental coverage for Medicaid-enrolled adults. The data

convincingly show that providing comprehensive dental

coverage for Medicaid-enrolled adults is a major driver

of access to dental care and improved oral health. We

then estimate the fiscal impact of implementing

comprehensive dental coverage for adults in the 28

state Medicaid programs that currently do not provide

such coverage. Our analysis includes estimates of how

many more adults would seek dental care and the

associated dental care costs as well as medical care

cost savings stemming from improved oral health for

those with chronic conditions like diabetes and heart

disease. We also discuss federal policy options to

ensure that all states offer adequate adult dental

coverage in Medicaid that could reduce cost barriers

and improve access to dental care for adults across

the United States.

Financial Barriers to Dental Care by

Income, Age, and Race

Dental care has the highest level of financial barriers

compared to any other health care service.

Financial

factors such as lack of insurance and cost being too

high are much more limiting to dental care access than

non-financial factors (e.g., fear of dentist, difficulty

finding an appointment time).

This is true for all age

groups and income levels. But the data clearly show

that out of any age group and income group, low-

income adults face the most significant cost barriers to

dental care.

Figure 1 summarizes the latest available data on cost

barriers to dental care. Within any particular income

group, adults consistently face higher cost barriers to

dental care than children or seniors. Children have, by

far, the lowest levels of cost barriers to dental care.

Further, within any particular age group, there is a

significant income gradient in cost barriers to dental

care. Low-income adults face the most significant cost

barriers to dental care out of any age and income

group.

Figure 1: Prevalence of Cost Barriers to Dental Care by Age and Income Level

Source: Health Policy Institute analysis of National Health Interview Survey data for 2019. Note: Percentages indicate those who

needed dental care but did not obtain it in the past 12 months due to cost. FPL: federal poverty level.

Financial barriers to dental care for low-income adults

have consequences. Low-income adults are least likely

to access dental care, including basic preventive

services.

Low-income adults are more likely than their

higher income peers to experience dental pain, to

report a poor overall condition of their mouth and teeth,

and to find life in general to be less satisfying due to

the condition of their mouth and teeth.

Further, poor

oral health also has economic consequences for low-

income adults. Research indicates that nearly 30

percent of low-income adults in the U.S. indicate that

the condition of their mouth and teeth limits their ability

to interview for a job.

There are also racial and ethnic disparities in oral

health care access that are important to highlight.

Black and Hispanic adults are more likely to face cost

barriers to dental care than White adults, and this gap

has been increasing over time.

Among children, cost

barriers to dental care have been narrowing across all

racial and ethnic categories. Black and Hispanic adults

are also less likely to have had a dental visit compared

to their White and Asian peers. Racial and ethnic

disparities in dental care utilization among children

have been decreasing.

15%

24%

26%

32%

0% 5% 10% 15% 20% 25% 30% 35%

Seniors (Age 65+)

Adults (Age 19-64)

Children (Age 2-18)

Low-Income (<133% FPL) Middle-Income (133%-399% FPL) High-Income (400%+ FPL)

The Impact of Medicaid Adult Dental

Coverage on Access to Care, Health

Care Costs, and Employability

There is a clear link between Medicaid policy on dental

coverage for adults and cost barriers to dental care,

dental care utilization, oral health status, and

employability. A recent study concluded that when

adults gain dental coverage through Medicaid, they

report improved oral health and employability.

These

outcomes were most pronounced among Black

Medicaid enrollees and those who had gone without

dental coverage for more than a year, suggesting that

dental coverage has the potential to reduce income

and race-based inequities in the oral health care

delivery system. Studies show that providing dental

coverage to adults in Medicaid programs significantly

increases access to and utilization of dental care.

There are spillover effects for children, as children who

reside in states that provide Medicaid adult dental

coverage to their parents are more likely to have had a

dental visit in the past year and less likely to have

deferred dental care.

There are economic benefits to adult dental coverage

in Medicaid. Among Medicaid-enrolled adults in states

that do not provide dental coverage to adults in their

Medicaid program, 60 percent reported that the

appearance of their mouth and teeth affects their ability

to interview for a job.

For those in states with dental

coverage for adults, it was much lower, at 35 percent.

More broadly, improved oral health could broaden

employment prospects and promote economic activity

in the community.

Expanded dental coverage can reduce overall medical

costs. Studies have repeatedly shown that dental

coverage significantly reduces costly emergency

department visits for dental conditions.

These cost

savings are realized by diverting care from hospital

emergency departments to more cost-effective settings

like a dental office or community health center. This

diversion can also lead to better oral health outcomes

because patients will get more clinically appropriate

treatment for dental conditions by dental professionals.

There is also emerging evidence that increased access

to dental care can lead to lower medical care costs

among patients who are pregnant or who have chronic

conditions such as diabetes and heart disease.

The Current Landscape of Adult

Dental Coverage within State Medicaid

Programs

Despite the overwhelming evidence of major costs

barriers to dental care among low-income adults and

the importance of coverage in alleviating cost barriers,

many states still do not provide adequate Medicaid

adult dental benefits. As of early 2021, 21 states and

the District of Columbia provide extensive adult dental

benefits in their Medicaid programs. Sixteen states

provide limited benefits, nine provide emergency-only

benefits, three provide no benefits, and one has a

dental benefit under development.

(Figure 2).

All states are required to comply with the Early and

Periodic Screening, Diagnostic and Treatment

(EPSDT) benefit to provide preventive and medically

necessary comprehensive health care services for

children under age 21 enrolled in Medicaid and the

Children’s Health Insurance Program (CHIP), including

dental care.

EPSDT offers a crucial guide to states in

the design of dental benefits packages for children: a

minimally acceptable set of services at its worst and a

north star of comprehensive, timely, individualized

dental care at its best – while still allowing flexibility to

align with the needs, resources, and capacities of each

individual state. There is no corresponding dental care

requirement for adult Medicaid enrollees; adult dental

coverage is optional under state Medicaid programs.

When a Medicaid-enrolled child enters adulthood, their

medical coverage transitions relatively seamlessly.

This does not hold true for dental care. In many states,

dental coverage is abruptly curtailed or taken away

entirely from Medicaid enrollees at the arbitrary age of

21.

Figure 2: Adult Medicaid Dental Benefit Level by State

Source: Health Policy Institute analysis of data from Center for Health Care Strategies, Inc.

Authors have updated the analysis with

data as of early 2021. Note: None = No coverage. Emergency-only = Coverage for pain relief under defined emergency situations.

Limited = Coverage for a subset of diagnostic, preventive, and minor restorative procedures with a per-enrollee annual maximum

expenditure of $1,000 or less. Extensive = Coverage for a more comprehensive mix of services, including at least 100 diagnostic,

preventive, and restorative procedures, and a per-enrollee annual maximum expenditure of at least $1,000.

Even in states that offer dental coverage for adults,

there are limits on the covered services or caps on the

amount of care enrollees can receive. Limited

coverage may focus on prevention or emergency care,

but does little to restore and/or maintain oral health for

Medicaid enrollees to prevent more severe and costly

oral disease. States’ decisions not to offer meaningful

dental coverage are usually based on fiscal

considerations that overlook potential cost savings,

and oral health benefits have historically been cut in

tight budget years. Dental benefits for adults have

neither been considered a “mandatory service” within

Medicaid nor an “essential health benefit” under the

Affordable Care Act.

Estimating the Cost to Provide

Extensive Adult Dental Coverage in

Medicaid in all States

We estimated the cost of providing adult dental

coverage in all state Medicaid programs. This involved

estimating the impact of adding extensive adult dental

coverage in the 28 state Medicaid programs that

currently provide either no coverage, emergency-only

coverage, or limited coverage. We estimated the

increased dental care costs as well as the offsetting

medical care cost savings from diabetes, heart

disease, and pregnancy – three conditions for which

there is reasonable evidence linking improved access

to dental care with medical cost savings. We estimated

both the federal and state government shares of

spending. Due to data constraints, we were not able to

estimate the cost savings from reductions in

emergency department use for dental conditions. Thus,

our analysis is conservative, erring on overestimating

the net cost. The detailed methodology is in Appendix

A. We summarize the key findings here.

Across all 28 state Medicaid programs, the net cost of

providing extensive dental coverage to adults is $836

million per year. This includes an estimated $1.1 billion

per year in dental care costs and $273 million per year

in medical care savings. (Table 1).

Detailed state-by-state estimates are available in

Appendix B. For example, the estimated annual state

share of new dental care spending that would be

required to introduce an extensive adult dental benefit

in Medicaid ranges from $525,511 (South Dakota) to

$51,617,933 (Pennsylvania), with an average of

$14,338,362. The state share of reduction in annual

medical care costs range from $111,816 (Wyoming) to

$17,020,266 (Texas), with an average of $3,589,406.

The net annual cost to a state of adding an extensive

benefit ranges from $255,095 (Missouri) to

$46,252,487 (Pennsylvania), with an average of

$10,748,957.

Table 1: Estimated Additional Cost of Providing Extensive Medicaid Adult Dental Benefits in All States

Dental care

spending

Medical care

savings

Net cost

State share

$401,474,150

$100,503,357

$300,970,792

Federal share

$707,533,813

$172,623,476

$534,910,337

Total

$1,109,007,963

$273,126,834

$835,881,130

Per enrollee per month

$6.16

$1.52

$4.64

Note: Table reflects net cost estimates for 28 states combined that currently have no, emergency-only, or limited adult

Medicaid dental benefits. Estimates are annual. Due to data constraints, estimates do not include expected reductions in

emergency department spending for dental conditions. See Appendix A for full methodology.

From Analysis to Action

Improving Medicaid adult dental coverage is a sound

investment in health, economic opportunity, and racial

equity. If all states were to provide extensive dental

benefits, we would overcome some of the enormous

barriers that low-income adults currently face. Under

the current landscape, basic access to dental care is

generally higher in states with more comprehensive

Medicaid dental benefits. Therefore, a person’s oral

health – and thus overall health and economic

opportunity – is dependent upon where they live.

The fact that Medicaid adult dental coverage remains

optional for states exacerbates deep racial and

geographic disparities in access to oral health care and

oral health outcomes. It also perpetuates inequities in

chronic disease prevalence, maternal health,

employment opportunity, and economic mobility. The

communities most affected by the COVID-19 pandemic

also face the highest barriers to accessing the oral

health care they need to be healthy and function in

their daily lives. Black, Hispanic, and other

communities of color, as well as people in rural

communities and people with disabilities, stand to

benefit most from comprehensive adult dental

coverage in Medicaid.

The optional status of Medicaid adult dental coverage

means that states can take away these benefits at any

time. Medicaid adult dental benefits are often subject to

state budget cuts during economic downturns,

especially in states with more comprehensive

coverage. It also means that states may offer different

oral health coverage to people in different eligibility

categories, such as pregnant people or people with

disabilities. This narrow definition of benefits can be

confusing for enrollees and oral health providers,

especially when covered services change with state

budget fluctuations.

Recommendations

These problems, combined with this research, provide

important considerations for federal policy change

around oral health coverage in Medicaid. The most

straightforward way to address oral health access is

through federal policy that makes comprehensive oral

health coverage for adults a permanent part of the

Medicaid program for all states.

Congress can designate dental services as a

mandatory benefit category for all Medicaid-enrolled

adults. This statutory policy change would ensure that

all states offer comprehensive oral health coverage,

eliminating the extreme variation across states. It

would also reduce or eliminate the need for states,

providers, and enrollees to differentiate between

eligibility categories for the purposes of covering dental

services. This would further reduce uncertainty for

people who may currently only have access to dental

care during pregnancy or 60 days postpartum, and

may also serve to reduce the state administrative

burden of differentiating benefits for separate

categories of Medicaid enrollees.

In order to achieve the projected increases in oral

health care access, health outcomes, and cost savings

in this model, Congress could also consider policy

aimed at establishing a baseline of

comprehensiveness for adult dental services in

Medicaid. Policymakers can amend the current

statutory definition of Medicaid dental services to

address the full range of oral health conditions,

specifying categories of services as necessary.

Previous legislation, including the Comprehensive

Dental Reform Act of 2015, the Oral Health for Moms

Act, and the Mothers and Offspring Mortality and

Morbidity Awareness Act, have taken similar

approaches in defining oral health coverage for

pregnant and adult populations in Medicaid and CHIP.

In addition to expanding the statutory definition of

dental services, Congress may also rely on further

specification at the regulatory level, which would likely

be carried out by the Centers for Medicare and

Medicaid Services.

Another important federal policy consideration is

bolstering state budgets as states implement oral

health coverage. While our research is based on

existing Federal Medical Assistance Percentages

(FMAP) to determine state and federal costs, Congress

could consider increasing the FMAP for states to

support comprehensive oral health coverage.

Adequate funding of state Medicaid programs is

necessary for the successful implementation of a new

benefit.

Each of these policy options would make

improvements to our current patchwork of Medicaid

adult dental coverage, and the most thorough

approach would be to implement all three together.

Regardless of what solutions federal policymakers

consider, our research shows that they should also

take into account the full range of savings that oral

health policy change can offer. History shows that state

policymakers’ fiscal calculations around oral health

coverage are often shortsighted, failing to take into

account the costs to both governments and patients of

untreated dental disease, care sought in emergency

departments, and the impact of untreated oral health

problems on other chronic conditions. As shown in our

model, improving oral health coverage not only

improves enrollees’ health, but also reduces overall

medical care costs. Notably, while limitations in the

data meant that our model could not account for

potential cost savings associated with reductions in

emergency department visits at the state level, existing

literature estimates that up to 78 percent of these visits

could be diverted to more appropriate care settings

and the cost savings could be over $1,200 per visit.

The savings we estimate are therefore likely

conservative.

Even without federal action, this research is instructive

for states that do not currently provide extensive dental

benefits to people who rely on Medicaid. State

policymakers can improve their states’ Medicaid adult

dental benefits, as several have in recent years, and

realize these same potential improvements in access

to care and medical care cost savings.

This analysis required making several key assumptions

that, although guided by the best available evidence

and data, are subject to uncertainty. Nevertheless, we

feel we have incorporated the best available evidence

and data to guide our modeling. The analysis is meant

to assist policymakers in assessing the need for and

the fiscal impact of ensuring a comprehensive adult

dental benefit is available in all state Medicaid

programs. The Health Policy Institute, Families USA,

and Community Catalyst are eager to work with

policymakers on initiatives that will expand access to

dental care and promote oral health equity.

About the Authors

Marko Vujicic is chief economist and senior vice

president of the Health Policy Institute of the American

Dental Association. Vujicic previously worked for the

World Health Organization and World Bank. Chelsea

Fosse is a senior health policy analyst for the Health

Policy Institute of the American Dental Association and

a licensed dentist. Colin Reusch is a senior advisor for

oral health policy for Community Catalyst’s Dental

Access Project. Reusch previously served as director

of policy for the Children’s Dental Health Project

(CDHP). Melissa Burroughs is associate director for

strategic partnerships for Families USA., leading the

Oral Health for All Campaign.

Appendix A

Methods for Estimating the Cost of Comprehensive Adult Dental Coverage in Medicaid Programs in All

States

Baseline Adult Dental Benefit, Dental Care Use Rate, and Estimated Total Dental Care Costs by State

We utilized previously published classifications of each state’s Medicaid adult dental benefit: none, emergency-only,

limited, or extensive.

Emergency-only states cover pain relief under defined emergency situations. Limited states

cover a subset of diagnostic, preventive, and minor restorative procedures with a per-enrollee annual maximum

expenditure of $1,000 or less. Extensive states cover a more comprehensive mix of services, including at least 100

diagnostic, preventive, and restorative procedures, and a per-enrollee annual maximum expenditure of at least

$1,000.

Classifications from 2018 were used for baseline.

For the current benefit classifications, we updated the classification

for states that underwent changes to their benefits packages since the most recent publication (2019), including Alaska,

Virginia, and West Virginia, which have or will have extensive benefits in place in 2021. This also included Delaware,

which now has a limited benefit. In this research brief, we focus our modeling on the 28 states with no, emergency-only,

or limited Medicaid adult dental benefits. Utah is excluded from our analysis for data reasons mentioned below.

We relied on Medicaid de-identified claims data from the Transformed Medicaid Statistical Information System (T-

MSIS), maintained by the U.S. Centers for Medicare and Medicaid Services (CMS), to assess utilization of and

expenditures for dental services among Medicaid-enrolled adults.

Since 2014, states have provided T-MSIS detailed

information regarding Medicaid and CHIP enrollment, service utilization, and payments. As of 2018, all states and the

District of Columbia provide T-MSIS with claims data on a monthly basis. The most recent year of T-MSIS data

available is from 2018. Thus, 2018 was selected to calculate baseline utilization and expenditures. Dental claims are

contained in the other services (OT) claims tables, one of the T-MSIS Analytic Files (TAFs) housed in the Chronic

Condition Warehouse (CCW).

This research is part of a data use agreement (DUA) approved by CMS (DUA RSCH-

2020-5563: “The State of Oral Healthcare Use, Quality and Spending: Findings from Medicaid and CHIP Programs”).

We extracted all dental procedure codes that appear in the American Dental Association’s Codes on Dental Procedures

and Nomenclature (CDT) manual from the 2018 T-MSIS OT Medicaid tables.

For each state, we measured dental

care utilization as the proportion of enrolled individuals who had at least one dental claim in the year. Specifically, to

produce a state-level utilization rate, we compared the number of enrollees age 21 and over who were enrolled for 365

days and had any dental claim in the year to the total number of adult Medicaid enrollees who were enrolled for 365

days. Dental visits that took place in an emergency department were not included. We used the claim type indicator

variable from the OT header table to differentiate between managed care and fee-for-service (FFS) claims; payment

data is available for FFS claims, but not managed care claims. We aggregated the FFS payments for dental services

for all enrollees age 21 and over by state and calculated the average annual expenditure per dental patient (adult with

any dental claim in the year).

There is no baseline expenditure data available for Utah because all dental services are paid for under managed care

and not reported in T-MSIS, which inhibits its inclusion in the modeling. Therefore, Utah is excluded from our analysis.

We obtained Medicaid enrollment figures from CMS.

These data provide monthly enrollment by state, including total

Medicaid and CHIP enrollment and total Medicaid and CHIP child enrollment. We used data from December 2018 for

baseline and August 2020 (the most recently available final enrollment figures) for post-reform enrollment projections.

For most states, we estimated Medicaid adult enrollment by subtracting the child enrollment from the total enrollment.

Child enrollment data were missing for Tennessee in 2018 and for Arizona in 2018 and 2020. To address this data

shortcoming, we used CMS-416 data for 2018 and 2019, the most recent available, as the source for child enrollment

estimates for Arizona and Tennessee. We then subtracted that estimate from total enrollment to reach adult

enrollment.

Baseline Dental Care Use and Per Patient Spending by Classification of Adult Dental Benefit

To estimate the additional cost to the Medicaid program of introducing “extensive” adult dental benefits, we estimated

how many Medicaid adult enrollees would use dental care services in a given year after an adult dental benefit is

introduced and how much, on average, would be spent on each dental care patient. An “extensive” Medicaid adult

dental benefit is defined as a benefit that covers 100 or more dental procedures and has an annual benefit maximum at

or above $1,000 per patient per year.

We recognize there are significant drawbacks to this simplistic definition, but

there is not an alternative definition that has been published in the literature.

Evidence indicates that when adults covered by Medicaid have dental coverage newly available to them, there is an

increase in dental care use.

This may occur through the enhancement of an existing adult dental benefit (such

as from limited to extensive) or when additional adults become eligible for Medicaid (such as through income eligibility

with Medicaid expansion). Research has shown that the rate of dental care use increases in the range of 6-10

percentage points within one year of implementation of extensive benefits.

8,28,29

Adults with more generous benefits

packages are more likely to use dental care.

In our analysis, we assumed that the change in utilization in any given state will be dependent on the degree of benefit

change with the implementation of an extensive benefit. In other words, we predict there will be a greater increase in

utilization in states that currently have no adult dental benefit and implement an extensive benefit, compared to states

that currently have a limited benefit that is enhanced to be comprehensive. In Appendix A Table 1, we calculated the

average dental care utilization rate among Medicaid-enrolled adults by adult dental benefit type. The mean utilization at

baseline for all states with no adult dental benefit 0.9% percent, the mean utilization at baseline for all states with an

emergency-only adult dental benefit is 9.2 percent, and the mean utilization at baseline for all states with a limited adult

dental benefit is 21.8 percent. We compared the average utilization for each of the no benefit, emergency-only benefit,

and limited benefit groups to the average utilization in states with an extensive benefit.

Appendix A, Table 1: Utilization, Expenditures by Type of Adult Medicaid Dental Benefit

Adult Dental Benefit

Classification at

Baseline

Number of

States

Average Baseline

Utilization

Difference

Compared to

Extensive

Average Annual

Expenditures Per

Patient

None

0.9%

27.5%

$784

Emergency

9.2%

19.2%

$445

Limited

21.8%

6.5%

$281

Extensive

28.4%

$437

Source: Health Policy Institute analysis of data obtained from the Transformed Medicaid Statistical Information System

(T-MSIS), maintained by the U.S. Centers for Medicare and Medicaid Services (CMS).

The average percentage of Medicaid adults with a dental visit in a year across extensive states in 2018 was 28.4

percent. We used these differences (none vs. extensive, emergency-only vs. extensive, limited vs. extensive) to

calculate the state-specific increase in utilization with the implementation of an extensive benefit based on its baseline

utilization. We added 27.5 percent to the baseline dental care utilization rate for states without an adult dental benefit

(including New Hampshire, where the dental benefit is under development), 19.2 percent for states with an emergency-

only benefit, and 6.5 percent for states with an existing limited adult dental benefit.

We used a single estimate for dental expenditures per dental patient following the implementation of an extensive adult

dental benefit based on analysis of T-MSIS data. We used the average total dental expenditure paid by Medicaid

among Medicaid-enrolled adults with a dental visit within the year, averaged across states that provided an extensive

adult dental benefit in Medicaid in 2018. This yielded an average expenditure level of $437 per dental care patient per

year. We assumed that all expenditures related to implementing an extensive adult dental benefit are paid for by the

Medicaid program; we did not account for the possibility of patient copays or coinsurance.

In summary, to calculate the total incremental expenditure of implementing an extensive Medicaid adult dental benefit,

we used the following formula for each state:

Expenditure = Enrollment * Utilization Rate * Spending Per User

Post-Reform Projected Dental Care Use and Dental Care Spending

To determine the federal and state shares of the estimated Medicaid expenditures, we used the most recent (fiscal year

2021) federal medical assistance percentage (FMAP) for Medicaid.

In states that have expanded Medicaid eligibility, a greater share of the cost of services for the expansion population is

paid by the federal government. We did not factor this into the state and federal shares and recognize this as a potential

shortcoming. However, given this adjustment, Medicaid expansion states would see a lower share of expenditures

attributed to their state budgets.

Post-Reform Estimated Reduction in Medical Care Costs

We estimated medical care cost reductions associated with increased access to dental care for adult Medicaid

enrollees. There is emerging evidence that increased access to dental care can lead to lower health care costs among

pregnant patients and patients with chronic conditions such as diabetes and heart disease.

16,17

Medical Care Cost Savings: Emergency Department Visits

The national average cost of an emergency department (ED) visit for a dental condition is $1,286.

The available

evidence suggests that up to 78 percent of ED visits for dental conditions nationwide could be diverted to a dentist

office or other ambulatory setting.

A recent study demonstrated a 14 percent reduction in dental-related ED visits one

year after expanding dental benefits via Medicaid expansion.

For methodological reasons, we did not include in this analysis the savings from reductions in ED use for dental

conditions. The costs for dental-related ED visits are not included in the baseline dental spending due to the

construction of these expenses in the T-MSIS dataset. Therefore, we did not model the offsets. Thus, our baseline

spending is an underestimate in terms of total dental care spending without the inclusion of ED associated costs of

dental care. However, additional savings would be projected due to the diversion of ED-based dental care to more cost-

effective and clinically appropriate settings when adult enrollees have an extensive adult dental benefit.

14,15,34

Medical Care Cost Savings: Diabetes and Coronary Artery Disease

We estimated the number of Medicaid enrollees in each state who have diabetes and coronary artery disease based on

the share nationally of adult Medicaid enrollees who have these health conditions. In the most recent year reported

(2018), 11.4 percent of Medicaid enrollees nationwide self-reported they had diabetes and 3 percent reported they had

coronary artery disease.

We applied the national rates for these chronic conditions among Medicaid enrollees to all

states. We assumed adults with these conditions will behave similarly in terms of their dental care seeking behavior

when an extensive dental benefit for adults is introduced. In other words, their dental care utilization rate will increase

by the same amount as adult enrollees in general.

We assumed that 60 percent of adult Medicaid enrollees have some form of periodontal disease. This estimate is

based on the most recent national data on the prevalence of periodontal disease among low-income adults in the U.S.

This 60 percent estimate also applies to pregnant enrollees.

Based on the available evidence, estimated medical costs would be reduced between $900

and $2,840

per patient

with diabetes who receives periodontal treatment. We used the lower end of this range and assumed a medical care

cost reduction of $900 per year for each new dental patient with diabetes once in a “steady state.” The available

evidence suggests that medical cost savings among adults with coronary artery disease who receive periodontal

treatment are $1,090

per year.

Medical Care Cost Savings: Pregnancy

We utilized the most recently available (2018) state-level data on the number of births among Medicaid,

but

subtracted the number of teen births by state.

Approximately 77.5 percent of teen births nationally are paid for by

Medicaid,

so that share of 2018 teen births were subtracted from each states’ total overall births to produce an

approximate number of pregnancies in Medicaid in each state. We assumed that pregnant enrollees will behave

similarly in terms of their dental care seeking behavior when a dental benefit for adults is introduced into Medicaid,

meaning their utilization rate will increase by the same amount as other adult enrollees.

Based on the available evidence, the estimated medical cost savings are between $1,500 (second pregnancy) and

$2,400 (first pregnancy) per year per pregnant woman receiving periodontal treatment.

For our modeling, we chose

the low end of this range and assumed a medical cost reduction of $1,500 per year per pregnant enrollee.

In summary, the medical care spending offsets for these various conditions is estimated using the following formula:

Medical Care Offset = Enrollees * Change in Utilization Rate * Share of Enrollees with Condition * Share with Condition

with Periodontal Disease * Medical Care Costs

Similar to the new dental care costs, we used the FMAP to distribute these medical care cost offsets across state and

federal budgets.

Cost of Adding an Extensive Dental Benefit by State

The impact of introducing comprehensive adult dental benefits in Medicaid, particularly the medical cost savings, is not

immediate. There is very little research to draw on to predict when these costs and savings would be realized following

the implementation of comprehensive benefits and how long this takes in practice. Enrollees become aware of the

benefit gradually, providers need time to adjust,

and medical care cost reductions are not realized immediately. For

simplification purposes, our analysis does not account for these time lags. Rather, it is best interpreted as “steady state”

estimate, likely to be most accurate over a two to five-year timeframe.

Appendix B

Estimated Cost of Comprehensive Adult Dental Coverage in Medicaid Programs in All States without an

Extensive Benefit

Baseline

dental

benefit for

adults

Adult

Medicaid

enrollment

Baseline

dental

care

utilization

rate

Projected

dental

care

utilization

rate

Additional

dental care

spending

Additional

medical

care

savings

Net cost

Net

Cost

per

enrollee

per

month

State

of net

cost

Alabama

None

283,788

0.1%

27.6%

$34,124,292

$12,782,664

$21,341,628

$6.27

27.6%

Maryland

None

759,189

13.3%

40.8%

$57,275,116

$23,521,013

$33,754,102

$3.71

50.0%

Tennessee

None

667,145

1.3%

28.8%

$77,896,427

$23,536,106

$54,360,321

$6.79

33.6%

New

Hampshire

Under

Development

105,181

7.5%

35.0%

$13,778,918

$3,048,687

$10,730,231

$8.50

50.0%

Arizona

Emergency

933,564

4.4%

23.6%

$93,699,447

$21,444,043

$72,255,404

$6.45

30.0%

Florida

Emergency

1,372,790

8.8%

28.0%

$97,020,830

$38,916,328

$58,104,502

$3.53

39.0%

Georgia

Emergency

604,272

9.6%

28.8%

$53,774,304

$18,686,512

$35,087,793

$4.84

33.2%

Maine

Emergency

127,662

10.7%

29.9%

$12,226,687

$2,763,428

$9,463,259

$6.18

36.0%

Mississippi

Emergency

211,101

11.4%

30.6%

$20,182,841

$6,940,708

$13,242,133

$5.23

21.7%

Nevada

Emergency

389,234

18.9%

38.1%

$21,691,113

$8,732,803

$12,958,309

$2.77

37.4%

Oklahoma

Emergency

259,116

9.2%

28.4%

$25,661,338

$8,052,508

$17,608,830

$5.66

31.7%

Texas

Emergency

997,541

5.3%

24.5%

$78,362,115

$43,419,045

$34,943,070

$2.92

39.2%

Arkansas

Limited

467,719

9.8%

16.3%

$24,152,533

$3,323,919

$20,828,614

$3.71

28.4%

Delaware

Limited

134,263

1.1%

7.6%

$3,142,452

$969,724

$2,172,729

$1.35

42.3%

Hawaii

Limited

214,504

8.1%

14.6%

$9,236,674

$1,423,569

$7,813,105

$3.04

46.4%

Indiana

Limited

813,254

26.6%

33.1%

$42,446,948

$6,040,819

$36,406,130

$3.73

33.7%

Kansas

Limited

124,954

17.0%

23.5%

$7,655,024

$1,241,970

$6,413,054

$4.28

39.8%

Kentucky

Limited

908,740

18.5%

25.0%

$68,802,428

$6,151,205

$62,651,223

$5.75

27.3%

Louisiana

Limited

886,412

14.1%

20.6%

$76,783,758

$6,736,875

$70,046,882

$6.59

32.0%

Michigan

Limited

1,529,074

26.1%

32.6%

$119,011,070

$10,586,689

$108,424,381

$5.91

34.5%

Minnesota

Limited

563,718

36.6%

43.1%

$18,673,023

$4,171,782

$14,501,241

$2.14

49.5%

Missouri

Limited

365,003

16.7%

23.2%

$4,129,885

$3,371,576

$758,309

$0.17

33.6%

Nebraska

Limited

91,781

37.0%

43.5%

$9,359,136

$951,469

$8,407,667

$7.63

42.2%

Pennsylvania

Limited

1,692,591

26.2%

32.7%

$109,082,699

$11,338,645

$97,744,055

$4.81

47.3%

South

Carolina

Limited

417,513

14.1%

20.6%

$21,430,923

$3,696,485

$17,734,438

$3.54

29.3%

South

Dakota

Limited

34,359

29.8%

36.3%

$1,272,115

$381,959

$890,156

$2.16

41.3%

Vermont

Limited

102,203

29.8%

36.3%

$6,673,414

$672,672

$6,000,743

$4.89

43.5%

Wyoming

Limited

21,160

20.2%

26.7%

$1,462,452

$223,631

$1,238,821

$4.88

50.0%

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